Wellness

[CelticCrafter]

Does any one know if there are different codes for medical care vs. post surgery care?

The insurance company is denying a claim for post surgery care and before I appeal it, I want to have my ducks all in a row and be sure the doctor used the right code.

[CatLoverDogsToo]

I haven't been involved in this for quite some time, but when I was working, post op visits are considered part of the surgery for a certain amount of time and therefore are not paid separately, unless the visit has absolutely nothing to do with the surgery.  

If I am remembering correctly, post op care was not separately remibursed for 60 days.( X-rays however are reimbursed post op)Evaluation and dressing changes were not paid separately unless there was a complication requiring additional care not included in the original procedure. 

If in fact a visit required something additional, a correct coding would have a modifier added to the code to reflect that.  Visit codes usually begin with 99___. 

Hopefully someone with more current knowledge than I have will chime in soon.

(If the doctor's office believes it was denied in error, they should be resubmitting the claim with documentation supporting it.)

[KathyPet]

there are thousands of different medical codes and all it takes is a coding error to have a claim denied.  YOur first step,should be a conversation with the billing dept at the medical provider's office (hospital, doctor).  they will investigate to ensure the correct code was assigned for the care received or procedure performed.

[SteelerFaninMD]

I don't know about post-surgery, but based on my recent situation, (emergency gall bladder surgery with a 6-day hospital stay due to infection/complications), it was coded as "routine".  The surgeon was out of network, so insurance initally declined to pay.  I have filed an appeal, and also notified by company's HR rep.  Currently working on assumption that there should have been a separate code for "emergency".  Likely assume you've got a similar issue.  If you have an employer/HR benefits rep, might reach out to him/her for assistance.  Good luck!

[CelticCrafter]

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@SteelerFaninMD wrote:

I don't know about post-surgery, but based on my recent situation, (emergency gall bladder surgery with a 6-day hospital stay due to infection/complications), it was coded as "routine".  The surgeon was out of network, so insurance initally declined to pay.  I have filed an appeal, and also notified by company's HR rep.  Currently working on assumption that there should have been a separate code for "emergency".  Likely assume you've got a similar issue.  If you have an employer/HR benefits rep, might reach out to him/her for assistance.  Good luck!

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@SteelerFaninMD - I could have written your story, it's the exact same situation as far as the type of surgery and the raging infection.

Even though the surgeon was out of network, the insurance company did allow what they would normally pay to a network surgeon because it was an emergency.  

[CelticCrafter]

@CatLoverDogsToo   I had a feeling that post op care should be included as part of the whole procedure because it was routine care to make sure the drainage hole was healing properly.

[m0rgan]

Google the medical code and see if you feel it is right for your care.  I would call the doctor's office and tell them your insurance denied the claim and have them check and see if it was properly coded, then appeal it.  Whenever I appealed I always won on appeal.  I think the insurance companies try not to pay and when they see you appeal they know you are serious.  Be very detailed on your appeal but don't make it too long.  My insurance company denied my vitamin D test and turns out my doctor's office didn't code it properly.  You have to stand up for yourself and keep good notes about who you talk to and when and when you send in appeals.  You only have 60 days to appeal.  It is really annoying to appeal and time consuming but when you have insurance you are supposed to be covered.  Don't let them get away with it.

[redwingsgal]

I agree with other posters here, and like @CatLoverDogsToo, I have not been involved with this part of the medical practice in quite some time.  When I was doing A/R for many many years, I always did the appeal.  The insurance company will need info that is not normally available to a patient (op reports, diagnosis etc)  After working for Ortho and CVT surgeons for many years, most all post-op is included in the surgery charge unless you are seeing a different doctor for the post-op, maybe one in network??  

To those posters who stated that they did the appeal, you did the work that the doctor's office should have done (or whomever is doing their A/R)

If an emergent surgery was denied, my guess is that the diagnosis code was not reflective as emergent

Good luck in getting this taken care of

[HerRoyaLioness]

Just wanted to point out that are always 2 codes applied to the visit.  One is the CPT (procedure code, what they did) and the other is the diagnosis code/s (why they did it).

This can be very important as some insurances will only pay for certain services (CPT code) for certain diagnoses.

It is difficult to give information if we don't know the procedure codes or the code for the postop visit (and diagnosis), because different ones have different global days where you cannot be charged within that time period for a related visit unless there is a complication.  Some have 10 days, some have 60 days, some have zero days - it depends on the procedure.

There are no simple answers, coding is very complicated - I would try and talk to a coder in your drs office who can explain it or your ins co as to exactly why they are denying something, until you understand it.

[luvdoodles]

I was a medical claims processor about 20 years ago for about five years. Your pre-op office and a post-op is all inclusive in your surgery bill. I had surgery on my back about a year ago and I did not have to pay for those visits. The billing dept must have coded it wrong. I would ask them for the code they used. You should be completely covered up to the amount allowed by your ins company and you are not responsible the balance. Definitely look into it.